Nissen Fundoplication Procedure Illustration Essay

Abstract

Introduction

As we proceed towards more and more day care surgeries we always need to choose patients and procedures within a great deal of safety margin. Anti reflux surgeries are gaining more popularity and awareness and Laparoscopic Nissen Rosetti fundoplication is a safe and effective method of performing them.

Methods and observations

Our case series of 25 patients who underwent day care Laparoscopic Nissen Rossetti fundoplication done over a period of 3 years suggests the feasibility and safety of performing day care anti reflux surgeries with no complications.

Discussion

Surgical outcomes of procedure are unaffected and the main challenge faced remains pain relief and which can be effectively tackled by local blocks or plain NSAIDs.

Results

Laparoscopic Nissen Rossetti fundoplication is a safe procedure to be offered as day care anti-reflux surgery. We encourage more studies in this regards with appropriate blinding to enforce its possibility as day care surgery and help patients with early recovery and decreasing cost of surgeries.

Abstract

OBJECTIVES

Controversy exists regarding surgery for true short oesophagus (TSOE). We compared the results of thoracoscopic Collis gastroplasty–laparoscopic Nissen procedure for the treatment of TSOE with the results of standard laparoscopic Nissen fundoplication.

METHODS

Between 1995 and 2013, the Collis–Nissen procedure was performed in 65 patients who underwent minimally invasive surgery when the length of the abdominal oesophagus, measured intraoperatively after maximal oesophageal mediastinal mobilization, was ≤1.5 cm. The results of the Collis–Nissen procedure were frequency-matched according to age, sex and period of surgical treatment with those of 65 standard Nissen fundoplication procedures in patients with a length of the abdominal oesophagus >1.5 cm. Postoperative mortality and morbidity were evaluated according to the Accordion classification. The patients underwent a timed clinical–instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. Symptoms, oesophagitis and global results were graded according to semi-quantitative scales. The results were considered to be excellent in the absence of symptoms and oesophagitis, good if symptoms occurred two to four times a month in the absence of oesophagitis, fair if symptoms occurred two to four times a week in the presence of hyperaemia, oedema and/or microscopic oesophagitis and poor if symptoms occurred on a daily basis in the presence of any grade of endoscopic oesophagitis, hiatal hernia of any size or type, or the need for antireflux medical therapy. The follow-up time was calculated from the time of surgery to the last complete follow-up.

RESULTS

The postoperative mortality rate was 1.5% for the Collis–Nissen and 0 for the Nissen procedure. The postoperative complication rate was 24% for the Collis–Nissen and 7% for Nissen ( P = 0.001) procedure. The complication rate for the Collis–Nissen procedure was 43% in the first 32 cases and 6% in the last 33 cases ( P < 0.0001). The median follow-up period was 96 months. The results were: excellent in 27% of Collis–Nissen and 29% of Nissen; good in 64% of Collis–Nissen and 55% of Nissen; fair in 3% of Collis–Nissen and 11% of Nissen and poor in 6% of Collis–Nissen and 5% of Nissen ( P = 0.87).

CONCLUSIONS

In patients affected by a TSOE, the Collis–Nissen procedure may achieve equally satisfactory results as the standard Nissen procedure in uncomplicated patients.

CLINICAL REGISTRATION NUMBER

NCT02288988.

Gastro-oesophageal reflux disease, Short oesophagus, Hiatal hernia, Minimally invasive surgery

INTRODUCTION

True short oesophagus (TSOE) is diagnosed during surgery for gastro-oesophageal reflux disease (GORD) and hiatal hernia (HH) when the distance between the gastro-oesophageal (G-O) junction and the apex of the hiatus is shorter than 2 cm, after maximal mobilization of the distal thoracic oesophagus without any downward traction on the stomach [ 1 , 2 ]. A combined endoscopic–laparoscopic method demonstrated that TSOE is present in 20% of patients undergoing routine surgery for GORD [ 1 ], and in more than 50% of cases of Type III–IV HH [ 3 ]. Recent reports have confirmed the importance of diagnosing and electively treating TSOE to reduce the risk of anatomical recurrence after surgery [ 4–7 ]. Today, as in the past, a Collis gastroplasty is generally used to elongate the native oesophagus and allow the creation of a gastric tube (tubular neo-oesophagus) below the gastric folds [ 8 ]. Antireflux fundoplication and hiatoplasty are associated with the Collis gastroplasty [ 9 , 10 ]. Presently, this operation is routinely performed using minimally invasive techniques [ 1 , 11–14 ]. However, the mortality, morbidity and outcomes associated with these procedures remain controversial [ 15–19 ]. In light of the controversies regarding the results of surgery for the treatment of TSOE, some have proposed that this condition should not be treated with surgery [ 20 ], thus preventing patients with severe GORD from receiving definitive treatment. However, medical therapy may be required for prolonged periods or may not be effective [ 20–21 ]. The present paper originated from the assumption that, in the absence of randomized, multicentre studies designed to compare the surgical techniques used to treat TSOE, data obtained from a single-centre study could be useful to the surgical community, provided that such data are based on an objective intraoperative diagnosis of TSOE and rigorous follow-up. To evaluate the outcomes in patients who underwent left thoracoscopic Collis–laparoscopic Nissen technique for the treatment of TSOE and to contribute to clarifying some of the controversies on this topic, we compared pre- and postoperative data from a group of patients who underwent the Collis–Nissen procedure (CN group) with data from a control group of patients who underwent the standard laparoscopic Nissen procedure (SN group) during the same period.

PATIENTS AND METHODS

Between 1995 and 2013, 326 minimally invasive antireflux procedures were performed. All 326 patients had a standard preoperative work-up and postoperative follow-up programme.

In the present study, pre- and postoperative data from 65 (65/326, 20%) left thoracoscopic–laparoscopic Collis–Nissen operations [CN group, 27 women (41%), 38 men (58%); median age 57 years, first–third quartile (Q1–Q3) 44–66] and from a matched group of 65 patients who underwent the standard Nissen operation [SN group, 27 women (41%), 38 men (58%), median age 56 years, Q1–Q3 47–66] were compared. The SN group was selected from 261 (261/326, 80%) laparoscopic ‘floppy Nissen’ operations (146 women, 115 men; median age 50 years, Q1–Q3 39–61), using a sequence of random numbers (see Statistical methods). The need for surgical therapy was determined according to defined parameters [ 1 , 19 ], based on the current guidelines for GORD therapy [ 21 ]. The presence of a Type II–IV HH associated with severe symptoms in patients with a low operative risk was an indication for surgery [ 1 , 19 ].

Preoperatively, the patients routinely underwent symptom assessment, barium swallow, upper gastrointestinal (GI) endoscopy and oesophageal manometry. Postoperative 30-day mortality or in-hospital mortality if still not discharged at 30 days and postoperative morbidity were calculated. All-cause mortality was considered. Postoperative mortality and morbidity were classified according to the Accordion severity grading system of surgical complications [ 22 ].

Postoperatively, the patients participated in an outpatient clinical follow-up programme based on the clinical assessment of symptoms, endoscopy and barium swallow at 1, 3 and 5 years, and every 3 years thereafter. The follow-up duration was calculated from the day of surgery to the day that the patient underwent the most recent follow-up.

Reflux symptoms (RS), dysphagia (S), dyspepsia (D) and the grade of reflux oesophagitis (RO) were scored according to validated semi-quantitative scales [ 19 ] as well as the global evaluation resulting from the combination of various grades of RS, S, D and RO parameters (Table 1 ). Results were scored from excellent, to good, fair and poor according to the frequency and severity of symptoms, the severity of RO (Table 1 ) [ 19 ]. Cases in which a recurring HH was diagnosed by barium swallow (even an HH smaller than 2 cm), and cases in which continuous or timed medical therapy [H2 blockers and/or proton-pump inhibitors (PPIs)] was administered, were graded as ‘poor outcome’, also in the absence of symptoms or oesophagitis (RS0, S0, D0, RO0).

Table 1:

Semi-quantitative scales for the evaluation of RS, S, D, RO and overall results

RS0 = Absence of reflux symptoms 
RS1 = Spontaneous or postural retrosternal heartburn or pain and/or regurgitation occurring two to four times a month 
RS2 = Spontaneous or postural retrosternal heartburn or pain and/or regurgitation occurring two to four times a week, whether associated with occasional aspiration or not 
RS3 = Spontaneous or postural retrosternal heartburn or pain and/or regurgitation occurring on a daily basis, associated with frequent aspiration or not 
S0 = Absence of dysphagia 
S1 = Sticking of solid foods or liquids 2–4 times a month 
S2 = Sticking of solid foods or liquids 2–4 times a week 
S3 = Sticking of solid foods or liquids on a daily basis 
D0 = Absence of dyspepsia 
D1 = Dyspepsia occurring 2–4 times a month 
D2 = Dyspepsia occurring 2–4 times a week 
D3 = Dyspepsia occurring on a daily basis 
RO0 = Normal 
RO1 = Hyperaemia, oedema and/or histology-positive for reflux oesophagitis 
RO2 = Single or multiple non-confluent or confluent erosions 
RO3 = Deep ulcers, stenosis or Barrett's oesophagus 
Excellent = RS0, S0, D0, RO0 
Good = RS1, S1, D1, RO0 
Fair = RS2, S2, D2, RO1 
Poor = RS3 S3, D3, RO2–3 
RS0 = Absence of reflux symptoms 
RS1 = Spontaneous or postural retrosternal heartburn or pain and/or regurgitation occurring two to four times a month 
RS2 = Spontaneous or postural retrosternal heartburn or pain and/or regurgitation occurring two to four times a week, whether associated with occasional aspiration or not 
RS3 = Spontaneous or postural retrosternal heartburn or pain and/or regurgitation occurring on a daily basis, associated with frequent aspiration or not 
S0 = Absence of dysphagia 
S1 = Sticking of solid foods or liquids 2–4 times a month 
S2 = Sticking of solid foods or liquids 2–4 times a week 
S3 = Sticking of solid foods or liquids on a daily basis 
D0 = Absence of dyspepsia 
D1 = Dyspepsia occurring 2–4 times a month 
D2 = Dyspepsia occurring 2–4 times a week 
D3 = Dyspepsia occurring on a daily basis 
RO0 = Normal 
RO1 = Hyperaemia, oedema and/or histology-positive for reflux oesophagitis 
RO2 = Single or multiple non-confluent or confluent erosions 
RO3 = Deep ulcers, stenosis or Barrett's oesophagus 
Excellent = RS0, S0, D0, RO0 
Good = RS1, S1, D1, RO0 
Fair = RS2, S2, D2, RO1 
Poor = RS3 S3, D3, RO2–3 

View Large

Barium swallow was performed pre- and postoperatively according to a dedicated technique intended to define the relationship between the G-O junction and the diaphragmatic hiatus in the upright and supine positions [ 19 ]; different types of HH were classified according to the radiological standards adopted in the literature [ 1 , 3 , 19 ].

Upper GI endoscopy was performed using standard methods; RO was initially categorized according to the modified Savary-Miller criteria [ 19 ] and was subsequently categorized according to the Los Angeles classification [ 1 ]. Oesophageal manometry was performed using the slow pull-through technique, in which the catheter was withdrawn in increments of 1 cm/10 s [ 19 ].

In the absence of Grade A or more severe oesophagitis, patients underwent 24-h pH recording or intraluminal impedance/pH monitoring.

Surgery

The patient is placed in the lithotomy position; the pelvis and left chest are lifted 45° to the right to facilitate access for a left thoracostomy along the posterior axillary line (Fig. 1 ).

Surgery begins via the placement of five laparoscopic ports (Fig. 1 ): the camera port is placed 5–10 cm above the umbilicus, depending on the patient's body size, to enable access to the upper portion of the mediastinum. After opening the phreno-oesophageal membrane, the G-O junction is isolated and the sac and fat pad (with the exception of the fat near the lesser curvature to preserve the integrity of the vagus nerves) are resected. A fibre-optic endoscope is inserted transorally to determine the position of the upper margins of the gastric folds, which correspond to the G-O junction. The tip of the endoscope is placed at this level, which the surgeon marks it with two clips. The intrathoracic oesophagus is mobilized by 9–12 cm to the level at which the left vagus nerve travels along the anterior aspect of the oesophagus.

The distance between the G-O junction and the apex of the hiatus is measured after completely releasing the stomach using an L-shaped instrument, which prevents errors due to the 2D video image. The upper arm of the L (90° based on the axis of the measurer) is placed at the apex of the diaphragm, and the distance between the base of the arm and the clip is measured in centimetres; the measurement is positive if the junction is above and negative if the junction is below the diaphragm (Video 1 ). This technique has been described in detail previously [ 1 ].

Video 1: Measurement of the distance between the gastro-oesophageal junction and the apex of the hiatus with an L-shaped instrument, performed after completely releasing the stomach.

Close

The intra-abdominal portion of the oesophagus must be approximately 2 cm long to permit a tension-free fundoplication [ 2 ]. To perform the oesophageal lengthening procedure, it is necessary to divide at least two short vessels. By turning the operating table towards the right side of the patient, the surgeon may simultaneously operate through the aforementioned five standard laparoscopic ports, as well as a left thoracoscopic port through which the instrument used to lengthen the oesophagus is inserted. A thoracostomy is performed at the posterior axillary line at the V, VI or VII intercostal spaces, depending on the patient's body shape and size. A 12-mm valvular trocar may be used to prevent loss of pneumoperitoneum and to control the intrathoracic pressure.

The anaesthesiologist passes a 46-Fr Maloney bougie into the oesophagus and then into the proximal stomach.

A no. 45 Endo GIA™ is inserted through the thoracic port; the tip of the instrument is delicately pressed against the left diaphragm to visually control the progression of the stapler from the port to the mediastinum. The stapler is fully visible through the hiatus as it penetrates the left mediastinal pleura. When it enters the abdominal cavity, the jaws are rotated towards the patient's left side.

The stapler is opened and positioned at the angle of His with its arms parallel to the Maloney bougie. To facilitate this manoeuvre and prevent the formation of a pouch between the suture lines and the angle of His, it may be necessary to pull the gastric fundus to the left when using the stapler.

The neo-oesophagus is approximately 3 cm long. The mechanical suture line is covered with a sero-muscular running suture. A hiatoplasty is routinely performed; in patients with a Type II–IV HH, the sutures placed in the diaphragmatic crura are reinforced with polytetrafluoroethylene-pledgeted sutures (two for each stitch, placed laterally at the edges of the crura and over the peritoneum) [ 3 ]. A standard technique of fundoplication is used, with or without the Collis gastroplasty. A ‘floppy Nissen’ fundoplication (one 1.5-cm U stitch reinforced with pledgets) is performed. The superior edges of the fundoplication are placed above the clips, which mark the native G-O junction, to fully wrap the neo-oesophagus. Two vertical U stitches intended to grab the inner, circular, muscular layer are applied laterally between the fundus and the oesophagus to prevent slippage.

Institutional review board approval

The present study was conducted in accordance with the ethical standards of the Helsinki Declaration (1964, amended most recently in 2008) of the World Medical Association. The local IRB (IRST IRCCS Area Vasta Romagna) approved the use of the database for this retrospective review of the case files. Each patient provided written consent, and all patient information, including illustrations, was anonymized. The study has been registered on ClinicalTrials.gov, with the identifier NCT02288988.

Statistical analysis

The data are expressed as median values and first–third quartile (Q1–Q3) unless otherwise stated.

To perform the statistical comparison between the results achieved in the 65 patients who underwent the CN operation and in the 65 patients who underwent the SN operation, a frequency-matched control group was selected from the general database using a sequence of random numbers according to age, sex and the period during which the study group was enrolled.

The Mann–Whitney U -test was used for comparisons of ordinal qualitative variables, and the χ2 test or Fisher's test was used, as appropriate, to evaluate nominal qualitative variables. Student's t -test for unpaired data was performed for comparisons of continuous quantitative variables.

The Wilcoxon signed-rank test was used to compare preoperative and postoperative data.

A P -value of less than 0.05 was considered statistically significant. The statistical analyses were performed using the SPSS 13.0 software package (SPSS, Inc., Chicago, IL, USA).

RESULTS

Preoperative clinical patterns

Video 1: Measurement of the distance between the gastro-oesophageal junction and the apex of the hiatus with an L-shaped instrument, performed after completely releasing the stomach.

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